About just culture, a concept to assess and deal with errors, you can read here:
1. How Just Culture Was Established in Aviation
1.1. A Punitive or Blaming Culture
Mistakes Were Not Supposed to Happen
As in many industries and businesses, in aviation mistakes were not expected to occur. If someone had made an error nonetheless, he or she was held accountable, regardless of wether he or she really was to blame. Had there been any circumstances contributing to the mistake? What risks had existed already? Who else had been involved?
These important questions were not asked. Rather, the attention was on the search for a scapegoat and diciplinary measures.
Hidden Mistakes
As we know from our own lives, such a management of mistakes leads to a demoralising atmosphere in which fear of punishment prevails. Consequently, we feel that it is at least very tough to admit mistakes and take responsibility for them. Every now and then, someone will try to hide an error completely.
Missed Learning Opportunities
In addition, the organisation as a whole cannot obtain important insights into the causes of errors, crucial learning opportunities for everyone are missed. Hence, what is to be seen as a positive chance to eradicate an error permanently and, subsequently, to enhance safety, is lost.
Something Crucial Was Missing
The culture of avoiding mistakes at any cost was usually accompanied by a power gradient. In this overall structure, there was no place for a speak up, which plays an important role in today's crew resource management.
As a consequence, warnings about potential risks and further questions if someone was about to make an error were nonexistent. Moreover, how should one have dared to pass on important information after having been rejected several times before? This also held true in healthcare for a long time, when a resident presumed to question the instructions given by a consultant constructively.
1.2. A Non-Punitive or No-Blaming Culture
Trend Reversal in the 1990s
In aviation, it was noticed that due to the hiding of mistakes vital information, which was much needed in order to improve safety, was lost. Furthermore, one tried to mend the damage, which had been caused by constant fear and pressure.
Now, employees were encouraged to report mistakes and risks, as well as to contribute to safety concepts. Improvements of aviation safety were achieved.
The Atmosphere Should Not Be too Relaxed
As the reporting of mistakes involved amnesty, these were now being indicated, but the organisation was seen as accountable for them. The employees expected not to be punished.
This went so far that dangerous behaviour was even shown deliberately and repeatedly, which enhanced the risk of an unfavourable outcome. After all, one was not held accountable. It goes without saying that these were the boundaries of the concept.
1.3. Just Culture Was Created From These Insights
As we have seen, the above mentioned oppositional approaches were not ideal. Using these insights, just culture was created, at which we will take a closer look now.
2. This Is Just Culture
2.1. There Is No Translation Into German
The term "just culture" has never been translated into German. Nevertheless, the concept is known in German Aviation, as well. It stands for justice when assessing and punishing mistakes or searching for their root causes. Was the mistake made by a single person or is there a flaw in the system? What measures are therefore necessary? Was the mistake made inadvertently or deliberately?
2.2. The Characteristics of a Just Culture
Below, you will find the fundamental criteria of a just culture at a glance:
- a culture without any unfounded blame or punishment
- anyone can make a mistake at any time, regardless their position
- everyone has clearly defined tasks and responsibilities
- mistakes and potential risks should be reported honestly
- a speak up is valued
- errors are assessed justly, causes are explored
- the root causes are eliminated as far as possible, risks are minimised
- after anonymisation of the mistake a learning opportunity for everyone is created
- if guilty, the people involved are held accountable according to the previously agreed conditions
- gross negligence will be punished according to the regulations of the respective line of business, up to the loss of a professional licence
3. Professionalism Is Vital
A just culture to deal with mistakes and risks does not mean that an overall reduced performance is expected.
Everyone has to know their tasks and how to accomplish them with the right knowledge, skills and appropriate attitude. Moreover, everyone knows his or her responsibilities.
Especially high performers with huge expectations of themselves feel extremely uncomfortable when making mistakes. All they can do afterwards is to take the bull by the horns, admit the error, apologise and review it constructively together with their team, if applicable.
4. How to Set up a Just Culture
If we want to establish a just culture in our working environment, we benefit from taking the following steps together with our teams:
- we evaluate, what mistakes typically happen
- we continue to look for further errors
- we assess what safety guidelines exist and which ones we want to add
- we establish the boundaries of acceptable behaviour and errors
- we determine, how mistakes are reported and resolved
- we agree on the sanctions that apply to the mistakes according to existing professional frameworks
- we determine, when and how often we will inform everyone about the reported mistakes and the measures we have taken
5. How to Make the Success Visible
Success is measurable, which is why we should also make our success using just culture visible. To achieve this, we need to determine how often we will check the quantity and kinds of the reported mistakes. In addition, we agree on how to measure the success of our measures.
Our employees have a strong interest in learning about our joint successes. This will keep everyone motivated to continue to contribute to our just culture.
6. These Lines of Business Use Just Culture
The following lines of business have adopted just culture from aviation:
The healtcare system, in order to avoid mistakes which lead to injuries, illness and death of patients. Just culture adds to the enhancement of patient safety.
Maritime shipping, to prevent disastrous accidents, in which many people may lose their lives or serious environmental pollution may be caused.
The railroad industry, in which trains with several hundred souls on board are en route on tightly knit networks of tracks on a busy schedule. Mistakes when working the switches or when signs had been overlooked have had fatal consequences in the past.
7. In My Next Blog Article You Can Read About:
To which larger topic does just culture belong? Please find out in my next blog article.
You can find more blog articles at the bottom of my blog page.
Author: Eva-Maria Schottdorf
Date: October 28th 2021
After one year, the articles will be removed from the blog page, updated, augmented and turned into books. You can purchase these directly on the page "A Special CRM Book Series" . The first volume is already waiting there for you.